Registered Nurse: MDS/ Clinical Reimbursement Specialist

New Haven, CT 06519

Posted: 03/14/2019 Industry: Registered Nurse Pay Rate: 85,000- 100,000/ year

Horizon Healthcare Management, LLC is currently seeking a talented RN MDS/Clinical Reimbursement Specialist to join a progressive Skilled Nursing Facility in New Haven. He/she will be responsible for Medicare and Managed care reimbursement in the facility. The Clinical Reimbursement Coordinator is also responsible for regulatory compliance and quality improvement efforts in order to attain appropriate Medicare or Managed Care reimbursement. This position assimilates information from all necessary disciplines to maintain accuracy and compliance with the MDS process. By conducting concurrent MDS reviews, he/she assures the achievement of maximum allowable RUG categories, The Clinical Reimbursement Specialist works with facility team members to ensure that services offered meet or exceed federal, state and company standards and serves as a role model for ethical business practices according to health standards.


  • Facilitate Daily PPS and Weekly Medicare meeting
  • Knowledge of and compliance with HIPAA guidelines
  • Participate in Monthly Triple Check meeting to ensure billing accuracy.
  • Complete MDS's per schedule as required for Medicare, Managed care and OBRA schedules
  • Initiate/Update Care plans as required
  • Facilitate and coordinate with other disciplines to maintain care plan development and ongoing updates according to MDS schedule
  • Provide updates as required per Managed Care contract guidelines
  • Completion and issuance of denial letters, coordination of Medicare certification completion, review of skilled nursing documentation (including CNA documentation) to support skilled needs
  • Serve as the primary resource for MDS/PPS
  • Manage Medicare appeals process, and participate in Administrative Law Judge hearings as needed.
  • Stay current with changing regulations as they pertain to clinical reimbursement and coding.


  • Must be a Registered Nurse in good standing and licensed with applicable State Board of Nursing.
  • Previous MDS 3.0 experience preferred.
  • Excellent verbal and written communication skills.
  • Expert understanding of State and Federal RAI regulations.
  • Knowledge of CASPER reporting
  • Knowledge in writing/updating care plans as member of interdisciplinary team.
  • Knowledge of clinical reimbursement preferred.
  • Recommends changes in resident care, treatment, medications as identified during scheduled MDS process.
  • Complete accurate coding of MDS with information obtained from medical record review, resident, family and staff interviews.

About the Company

Horizon Healthcare Management, LLC is a professional healthcare staffing firm, which focuses on providing highly skilled health care professionals throughout the nation. We currently have contracts with facilities in over 18 states and growing fast! Our Mission is to create value in every position we fill, providing the highest levels of service with staff that are dedicated to being professional, friendly and caring.


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